[IPm] "Phantom" Bolus's

One of our pumper patients called the clinic yesterday complaining about
an ongoing pattern of lows yesterday morning through 2PM. We did
trouble shooting over the phone and started with reviewing his basal
rates and bolus's. He is on a D-Tron. When we got to the bolus screen,
he noted a mid am bolus that he didn't remember giving. He went back
through the bolus history and found 9 bolus's within an 8 minute time
frame. They were in increments of 0.1 to 1.0 for a total of 2.4 units.
As his ISF is 60, this explained his lows. However, he said he gave no
bolus's at that time, to his knowledge and in fact was driving in his
car.
After further investigation, calling Disetronic tech support and the
local rep, we determined that his seat belt buckle was hitting on the
"up" arrow and giving him a series of mini bolus's. There are 2 ways to
give a bolus on the D-tron. One is to just hit the "up" arrow until
you've reached the desired amount (his bolus rate was set in 0.1 unit
increments, but it can be set in 0.2, and 0.5 increments). You do not
have to hit any other button to confirm. Once the bolus starts, the
pump gives one beep and one vibration per increment. He did not hear
these as the pump was in his pants pocket, beneath a heavy winter coat.
The other way to give a bolus requires selecting the bolus screen,
setting the bolus, and then confirming, before delivery begins.
So, moral of the story on this one, for us, was to attach the optional
adhesive backed "0-ring" over the "up" arrow, to prevent future
accidental "phantom" bolus's.
It is a great pump, so, wanted to pass along this recent lesson we
learned.
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